Spinal Tuberculosis: Don't Forget the Posterior Elements

SPINAL TUBERCULOSIS : Don’t Forget the Posterior Elements

JD JAGIASI*, S AIYER*, JV PATANKAR**, AB GOREGAONKAR***
*Lecturer; **Associate Professor and Unit Chief; ***Professor and Head, Department of Orthopaedics, LTMGH and LTMMC, Sion, Mumbai 22.

A case of spinal tuberculosis is described, involving the posterior elements of the thoracic vertebra. An 18-year-old girl presented with sudden onset paraplegia. Patient was treated with posterior spinal decompression.

Paraplegia[4] has been most of the times a diagnostic and therapeutic problem for many years. Tuberculous[3] paraplegia can be acquired haematogenously or by direct spread. Most commonly tuberculosis affects the anterior part of the vertebral body, but here we have a case of tuberculosis spine involving the posterior element[2,3] of the vertebra.

CASE REPORT

An 18-year-old girl presented with sudden onset paraplegia.[4] Since 15 days she started complaining of pain in dorsal spine and developed sudden onset paraplegia. X-rays showed no obvious abnormality, her ESR being 80 mm at the end of 1 hr. MRI1 of the spine (Fig. 1) showed extradural posterior granulation tissue from D2-D7 compressing the cord.

TREATMENT

Patient was explored surgically with posterior midline approach and laminectomy of the apex at D5-D6 was performed, a thick membrane of granulation tissue was seen compressing the cord posteriorly which was excised very carefully since it was adherent to the cord and sent for histopathology which proved to be tuberculosis. Thus the cord was relieved of underlying pressure.

The patient had a gradual neurological recovery from Day 2 postoperatively and progressed to power of Grade 4 in both lower limbs over two weeks. She was put on complete bed rest for 6 weeks and then made to sit up using a spinal brace and then subsequently mobilised on a walker.

DISCUSSION

Posterior vertebral involvement in TB has been appreciated for many years (Jacob’s 1964) but is very uncommon. The incidence has been reported to be 0.2% (Adendorff, Boeke and Lazarus 1987) to 10% (Babhulkar, Tayade and Babhulkar 1984).[2,3] The spine should be dissected with utmost caution while removing the granulation tissue membrane covering the cord. Most of the patients of posterior element tuberculosis complain of backache for a long duration till they develop neurological deficit. So many times we have observed as in our above patient that they directly present with neurodeficit preceded by minor backache, some of the patients also have sensory deficit along with backache, which may be missed. Most of the patients are treated surgically, after confirming diagnosis on MRI.

CONCLUSION

Persistent backache should not be ignored, it must be closely observed to diagnose such pathology at an early stage. MRI plays a vital role in the diagnosis of the lesion and planning of management. Posterior element tuberculosis with neurological deficit whenever treated with surgical decompression shows dramatic recovery.

ACKNOWLEDGEMENT

Our acknowledgements to the Dean, and Head of Department, Orthopaedics of Lokmanya Tilak Municipal Medical College and Hospital, Sion for allowing us to publish this data.

REFERENCES

1.Al. Mulhim FA, Ibrahem EM, EL Hussain AY, et al. Magnetic resonance imaging of tuberculosis spondylitis. Spine 1995; 20 (21) : 1187-92.

2.Babhulkar SS, Tayado WB, Babhulkar SK. Atypical spinal tuberculosis. Journal of Bone and Joint Surgery 1984; 66B : 239-92.

3.Jayant AK. Atypical presentation of spinal tuberculosis proceedings of a combined meeting of the international bone and joint tuberculosis club and the European Bone and joint infection society Amsterdam. August 1617, 1996 as a pre SICCOT meeting. 1996; 20.

4.Tulli SM. Treatment of Neurological complication in tuberculosis of the spine. Journal of Bone and Joint Surgery 1969; 51A : 680-92.